Outreach

I wrote this blog entry and attempted to post it last week, but somehow everything except the pictures got deleted. I was pretty frustrated about it for a few days, which deterred me from blogging. But I figure I really should rewrite it and get on with other posts.

Last Tuesday I went on Outreach to Hukuntsi. It's a village about an hour flight by prop plane west of Gabs, pretty much in the middle of bush/desert. The idea behind outreach is to bring specialists to smaller hospitals to provide care for complicated patients. The government arranges for a private flight to take physicians and other providers from Gabs to the rural site for a day, and the team visits each of around 12 sites monthly. Our team consisted of a pediatrician (Peter, from BIPAI, who was leading a training session is a town about 100 km away, and met us there), an internal med doc employed by Penn, a peds resident, a physical therapist, two medical students from the University of Botswana, the BIPAI outreach coordinator, and me. We also brought around 10 boxes of antiretroviral medications to supply the hospital. The services provided each week varied depending on the team, but every team provides specialty care in adult HIV, peds HIV, and general pediatrics (pediatricians are considered specialists in Botswana, and there are fewer than 5 residing in the country--though there will soon be Botswana-trained pediatricians graduating from the new peds residency program). 

We were met at the tiny airport (i.e. a shack, a windsock, and a gravel runway) and driven about 5 minutes through town to the hospital. Although small, the hospital was the only medical center in the region, and some of our patients traveled 100 km or more to receive care. As we learned when we were asked to consult on a child who was being treated as an inpatient, the diagnostic technology available at the hospital was very limited. They were able to do x-rays, ultrasounds, and very basic blood work. They were not able to perform an echocardiogram, a CT, or a blood smear. Any patient requiring more extensive testing, including the HIV negative 15 year old with severe growth retardation, hepatosplenomegaly, and a hemoglobin on admission of 2.9 for whom we were consulted, required transfer to Princess Marina or another hospital in Gabs.

In addition to inpatient care, the hospital provides ambulatory care for patients in the region. We saw patients in the HIV clinic--a single exam room where patients are seen every Tuesday. The patients we saw at the pediatric HIV clinic were referred to us for a variety of reasons. The most common reason was virologic failure, which, in the majority of cases, is due to poor adherence. So, as in the clinic in Gabs, much of our work revolved around adherence training. We also saw patients who were being transitioned between medications (the government is currently phasing out stavudine due to its side effect profile--except in extreme circumstances, all patients are supposed to transition this month), patients with side effects (e.g. gynecomastia in a 14 year old boy from efaverenz or anemia), and, one girl with Kaposi Sarcoma, whose disease was worsening despite two rounds of chemotherapy.

Overall, the clinic was fairly similar to our clinic in Gabs, but there seemed to be a somewhat higher use of traditional medicine. One patient had recurrent viremia followed by periods of good control because his father did not believe in western medicine. His mother--who appeared ethnically San and wore a satchel like the medicine bag displayed on my parents wall along with western clothing--administered his antiretrovirals when she was in town. However, during her frequent trips out of town, the child's father withheld medication. The team decided to try to contact the father to ask him to attend the next visit. A less tragic example was the 9 year old girl with Kaposi Sarcoma. Hers was the first physical exam on which I have seen marks from traditional medicine. However, her mother followed all medical advice from physicians and diligently administered antiretrovirals and took the child for chemotherapy and follow up oncology appointments.

After seeing the HIV clinic patients and the consult on the peds ward, we returned to the airport for the flight back to Gaborone. We arrived back around sunset after a fascinating day.

Our prop plane

The team during the flight to Hukuntsi

Hukuntsi Hospital

The hospital "lobby" from which the wings opened. Like Princess Marina, the connecting spaces are covered walkways outside.

The medicine ward where we saw the peds consult, from the "lobby." More on the open doors to wards in my next post.

The guardhouse and ambulance in front of the hospital

A house of the drive back to the airport

The airport, complete with shack and gravel runway

Our plane at sunset, back in Gaborone

A mostly-pictures post

Here are photos from the weekend! I'll provide a bit of an overview of the weekend, but I think most of it is best shown by the pictures!

I started clinic on Friday shadowing, but there were a ton of patients to see, so they asked if I could start seeing patients on my own (both so I could see some patients and so the doctor I was working with could see patients more quickly). It was fairly overwhelming--there is some degree of language barrier, even if most students have to learn English. And I always have some trouble using a new EMR. But overall, everyone was polite and very helpful.

I tried to see teenage patients, who were more likely to speak fluent English. I found out that there is also a nurse who can translate when needed, so I may try to see some younger children on my own when she's available.

After clinic ended, at around 2 pm (apparently a pretty normal time, although it was the latest clinic ran all of last week), Whitney and I walked to the Main Mall to get lunch at a restaurant with local food that was recommended by a Penn resident we met the night before. The restaurant had finished serving lunch, but they prepared food for us--it look a long time, but I thought it was good. I then walked around the Main Mall, an outdoor plaza/strip mall with a wide variety of shops and street vendors targeted at locals and tourists, before heading home. 

Friday evening was the Freshlyground concert at Botswana Craft. We arrived early enough to see the first opening act, a performance by the marimba band from the Maru-a-Pula school (an elite boarding/day high school near our apartment where the other two Princeton in Africa people, besides my roommate Anette, work). The marimba band and the second opener were enjoyable, and Freshlygorund was excellent. I hadn't realized who the band was when I decided to go to the concert--they were the band that did the Waka Waka World Cup song with Shakira. Everyone at the concert was incredibly enthusiastic and the band were great performers with great music. The sold-out concert took place in a large outdoor courtyard, and the weather was perfect for it. After the band finished, the venue put on dance music and the floor in front of the stage became a dance party. Overall, it was a great experience and a great way to meet lots of incredibly friendly locals and visitors from around Africa and around the world!

Saturday morning we woke up pretty early to catch a ride to the Madikwe game reserve, a large reserve just over the border in South Africa, around 50 km away. At the border crossing, we met another group of tourists; they turned out to be the current group from Penn--3 fourth year students, one resident, and one spouse--and they were heading to the same camp for the weekend. We ended up being assigned to the same safari guide, which worked out great. After our game drive the first day, we had a surprise outdoor dinner in the bush by lantern-light/bonfire. It was a pretty awesome experience. Dinner conversation involved a lot of Oscar Pistorius jokes and lots of pretty racist comments on the part of our ranger about Chinese people and how they are going to destroy Africa. 

Disappointingly, people heard gun shots in the park Saturday morning, so rangers had closed down some roads due to safety concerns while they searched for the poachers. That meant we couldn't go to the area where the ranger expected we would be able to see cheetahs. The highlight of the trip, however, was seeing a pack of wild dogs. I think visitors normally see cheetahs and wild dogs at this park partially because of conservation/reintroduction efforts and partially because some animals are tagged so the rangers can find them more easily. It certainly makes it a less natural experience, but it is nice to be able to see animals. Overall, it was a lovely and relaxing weekend, and it was great to get connected with the Penn folks.

Tomorrow I'm doing outreach in Hukuntsi, a village in the Kgalagadi Dessert in Western Botswana (pop 4,500 according to wikipedia, it has a grocery store, 3 elementary schools, 1 secondary school, and a hospital). I need to be at the airport at 7 am and we'll fly out to the town in a small (10-12 seater) airplane. 

Outreach sounds like a very different experience than the clinic here. Our general role is to monitor HIV positive children in the community and provide antiretrovirals and other therapies, but it sounds like there is generally minimal access to healthcare so we may be asked to treat almost anything. One of the doctors at the clinic told me a story about a baby who was brought to the clinic with an abscess. They didn't have any I&D kits, sterile gloves, etc., but they were the only medical providers the baby would see, so they did what they could. It sounds pretty crazy. I'll write about it tomorrow or the day after and I'll try to include some photos.

Princess Marina Hospital. These are the actual hallways of the hospital. Literally, patients are rolled in stretchers down these walkways to get to surgery, etc. It's odd to be walking outside and be able to look into wards and see patients, but, aside from security being more difficult, I guess it's not that much less safe/sanitary than an American hospital. I just imagine a squirrel or bird getting into an OR, though. Maybe when I do a couple days there next week, I'll ask if that has ever happened. But I'll wait until the end of my second day, so they won't think I'm an idiot while I still have to interact with them.

The Main Mall in Gabs, which is pretty close to the hospital. I will have to come back to do some souvenir shopping, and to try the Pie Shop (savory, not sweet). It sounds pretty delicious.

The sun deck at the lodge, overlooking the watering hole. Sarah and Eli are talking to one of the guides.

Our cabin. I didn't fill out the guest questionaire in time, so they assumed that 2 guests under the name "Williams" were a couple. They gave us a double bed (which was huge, so it was fine), and there was a note on the bed saying, "Welcome Mr. and Mrs. Willam."

The bathroom with the outdoor shower. One of the CHOP residents who was there when we arrived had forgotten to shut the door to the bathroom while she was showering. When she came back in, there was a monkey in her bathroom. She said both of them were quite startled to see each other.

The second opening band

Freshlyground at their super-awesome concert

Zolani Mahola, the lead singer, was quite charismatic. And pregnant.

The very beginning of our game drive--we had to stop because there was a crocodile hanging out in the middle of the road.

Elephants at a watering hole. The park was interesting--there was a surprising amount of human intervention. Most of the watering holes are semi-man made, or at least man-filled, to be sure they had water year-round. Near the road a little way back from the watering hole was a large solar panel that ran a pump to keep the water from drying up.

Male elephant in musth, a period in which testosterone levels surge (according to wikipedia, to as much as 60x the normal level) and elephants become highly aggressive. Kenny had just banged on the side of our jeep, and the elephant was not happy with us.

A pack of wild dogs (or "African spotted dogs," as they have been re-dubbed in conservation efforts). There are fewer than 9,000 of them left in the world. They were beautiful! 

Like wolves, they regurgitate food to feed it to their young. I'm not sure if this dog was intended to feed its pack-mates baby-wolf-style, or if it just vomited and re-ate the meat because why should it go to waste. Regurgitating meat definitely brought the other dogs nearby over quickly, though.

The Toto lyrics regarding this particular animal never made much sense to me, but they make even less sense after learning more about the species. They're actually a lot like wolves--they live in packs and can't survive on their own. Nothing solitary about them.

Another bull elephant. This one was much more docile.

The dexterity of their trunks is incredible!

Lion! Plus Sarah and Eli.

Mom and cub

A bunch of cubs. In addition to size, cubs can be distinguished from adults by their spotted legs.

Surprise outdoor dinner in the bush. It was pretty awesome.

Mom and baby white rhinos

Black rhinos, which are much more rare, don't travel in pairs like this. White rhinos are much more sociable.

We spent all morning looking for a giraffe, and eventually found these two. Then got back to the lodge and there was one hanging out at the watering hole there.

The second giraffe we found. The older a giraffe is, the more dark area it had on it's body. This one is probably pretty old.

Male ostrich

Cattle walking down the highway on our way back to Gabs--this is a pretty common sight. There were actually cows on the side of the main road near our house the other day. It seemed strange because it's a quite suburban area with mostly fairly high-end housing. I have no idea where the closest cattle farm would be.

More about Clinic

Today was my third day of work, and it's amazing how much I have learned already. Both yesterday and today I entered much of the information into the EMR and I conducted several patient interviews. It's amazing how complex some of the cases can be; they are frequently both technically and socially challenging. 

For instance, today we saw a 16 year old girl who was diagnosed with HIV in 2011. Since her diagnosis, she has not taken her medication consistently. Last spring, she stopped taking her meds entirely for 2 weeks. Given the difference half lives of her medications, this period was sufficient for her to develop resistance to the NNRTI she was taking; the drug has a single mutation resistance barrier, so it is highly likely that the virus would mutate during the week+ period where the other two ART medications have been metabolized to a level too low to suppress the virus. After she was switched to another regimen, she continued to have poor adherence, and her viral load hasn't yet been suppressed. She is immunosuppressed, though she doesn't quite meet the definition of AIDS and has not yet had any opportunistic infections. It was incredibly frustrating to try to convince this girl that her life depends on taking the drugs correctly and that it's worth the inconvenience, stigma, and minor side effects to stay healthy. She was clearly an intelligent girl, but it's hard to convince teenagers of their mortality.

I saw a similar patient population yesterday in the Family Model Clinic; there as well, most of the patients were adolescents with complicated social situations. The most heartbreaking case was a 17 year old woman who had been sexually abused by multiple family members and family friends since age 9. She has been homeless on and off as she has tried to avoid men who have abused her. The clinicians presume that she contracted HIV from one of these men; she was diagnosed with HIV and was determined to be pregnant after a severe pneumonia. The baby was born premature and spent a month or more in the NICU. Within the past week, shortly after the woman and baby were discharged home, the baby died suddenly. The physician I was with commented that most people do not go through that much in a lifetime, let alone as a child. 

Most of the cases have been similar to these; most patients are children or adolescents coming from very challenging social situations. Many are orphans or have lost one parent to AIDS; many have unstable housing and no running water or electricity; the majority are angry about their disease and about how unfair it is to be born with HIV. The Baylor CCOE providers, however, seem to care deeply about their patients and consistently delve into any and all social details that may affect adherence. Much as I have been impressed with the physical facilities and resources the clinic provides, I am impressed with the superb quality of care and attention that patients receive. It is truly remarkable, particularly in a resource-limited setting, and the physicians provide an excellent example for me to emulate.

The other excitement of today was learning about the research I will be working on while I'm here. As I mentioned in my last post, resistance assays are routinely done in the U.S., but, due to cost, are ordered here only when a patient is suspected of having developed resistance to second line medications. I'm going to be working on the introduction and background section of the paper and doing a lit review on the clinical value of the assays. It should be interesting, and it would be pretty awesome to be a coauthor on a paper coming out of the clinic here!

I also made lots of fun plans for the weekend today. We got tickets to see a South African band, Freshly Ground, play tomorrow evening at Botswana Craft. The band is supposed to be very good, though my internet access is way too slow to try listening to their music, so I can't say for sure. It seems like a really fun venue and it's one of the largest in the city, though, so it should be a good time. On the way back from getting the tickets, we ended up sharing a cab with a HUP medicine resident who recommended tons of things to do in and around Gabs. On his recommendation, we're planning to go out for Batswana food for lunch tomorrow. Also on his suggestion, Whitney and I booked a one-night safari at Madikwe game preserve just over the border in South Africa. We got a great deal booking last minute, and the lodge is only about an hour away, plus the time it takes to cross the border. Anyway, lots of excitement to look forward to!

I promised photos of the clinic and my apartment. Here are a few:

Waiting room at the clinic (it's almost never this empty)

Another exam room, beautifully painted with a beautiful view

Hallway of the clinic with framed art, looking toward the waiting room

Outside view of the clinic

Part of our walk to and from work. Notice the 4 foot tall ant hill

The grounds of our apartment complex, looking toward the pool

Our apartment is the one on the third floor

First Day at BIPAI

After a fun, if uneventful, evening consisting of a group dinner of barbecued impala sausage (the impala was shot by the chef himself, a Bates grad here with Princeton in Africa) and a visit to the mall to re-watch Silver Linings Playbook (still good the second time around and fun to see after attending the JeffHOPE ball in the Ben ballroom), I unpacked, checked email, and got to bed before TOO late.

I woke up with the sun at 6 am, and arrived at work just after the morning hymn and prayer. I was given a brief introduction to the center, was taken on a tour, and then shadowed a doctor. Few patients were booked and even fewer showed up after the holiday weekend, so we only saw two patients. There was then lots of time to follow up on tasks, such as registering my fingerprints to allow access to the provider areas of the clinic. Yes, access and exit is by fingerprint. It's like sci-fi/action movie or a USMLE exam or something. Pretty freaking bad-ass for a clinic in a developing country.

In fact, the whole clinic was very impressive, regardless of the location. It appeared newer, more modernized, and better maintained than most of the clinics at residency programs where I interviewed. All exam rooms had flat screen monitors and an EMR that connected to a national system. The walls of the clinic are covered in art, and the providers seem to be experts in the field. The clinic not only follows clear guidelines for treatment, but has also been instrumental in the research on which world-wide guidelines are based.

Clinic exam room

The highlight of today, however, was the teaching by physicians at the clinic. I was most impressed by the preceptor for the day, Peter, an American physician who worked at the clinic as a resident and an attending. Peter seems to teach constantly and his knowledge base is enormous. He is also involved in a huge number of research projects and he invited Whitney (the other MS4) and me to participate in projects to work on a lit review and possibly get a co-authored publication. There are few things that will excite me quite like the opportunity to do clinical research (...I'm only kind of joking), so I'm hoping it works out for us to be involved. We'll meet with him on Thursday afternoon to discuss details. 

The other awesome thing Peter did today was go through basics of the clinic's treatment algorithm with us. Although it is clear that many practices that are standard in the US, such as viral genotyping before initiating antiretroviral therapy, are not possible with the limited resources available in Botswana. Additionally, there are medication classes within the US that are not available here. However, because the government receives money from its majority ownership of diamond mines--which in turn is possible because diamonds were only discovered after the country was given its independence--the resources available to treat HIV here are greater than in almost any other African country. It is one of the only countries that can afford to check viral loads, and it has more medications available than most other locations in sub-Saharan Africa.

There are three lines of therapy available, consisting of 4 classes of drugs, typically with several drugs available within each class. Virtually everyone is initially started on a non-nuc-based regimen unless they received PMTCT (prevention of maternal to child transmission) with a drug from the class in an attempt to prevent vertical transmission at birth. There are then protease inhibitor based regimens for second line or for children who received PMTCT, and there is salvage therapy available for patients who show viral resistance on genotyping (the one case in which testing is available).

The other interesting thing that Peter discussed with us was his theory on why Botswana developed greater rates of HIV than other countries. His suggestion was that the rapid spread was actually due to technology. In the 1980's as Botswana was working to develop infrastructure with the country's income from diamond mining, the country built the most extensive network of roads in southern Africa. He proposes that, in the same way that WWI facilitated the flu epidemic of 1917 and air transit facilitated the rapid spread of H1N1, roads may have facilitated the HIV epidemic in Botswana. He argues that, contrary to many popular explanations, rates of promiscuity are not significantly higher here than in the US (see below). Anyway, I decided I really want to find a development economist to coerce into analyzing the relationship between highways/infrastructure, promiscuity, and patterns of HIV spread.

Anyway, it was an awesome first day, and I'm incredibly excited to learn more about pediatric HIV treatment, the services the clinic provides, and about the country. Tomorrow I work in the Family Model Clinic, in which children with social risk factors or poor adherence and their close relatives are treated as a family unit.


Some fascinating facts about HIV and the Baylor clinic:

Current rate of positive HIV tests among infants referred to clinic: <4% (compared with 30-40% before the implementation of PMTCT treatment)

Cost of viral genotyping: 3,000 to 5,000 pula ($360 - 600)

Number of patients currently receiving care at the clinic: ~2,000 (however, with much lower rates of vertical transmission, and with lower horizontal transmission rates as HIV positive individuals are controlled on ART, the patient populations will likely decline. The clinic plans to expand to treat other childhood diseases as the need for HIV treatment declines)

Annual mortality among pediatric patients at the clinic: <1% (compared with 15-17% in other locations in sub-Saharan Africa)

Positive rate among patients tested for resistance with genotyping: 1/10 (other cases of suspected "treatment failure" are actually adherence issues)

Average number of sexual partners per adult male in the US: 1.1
Average in Botswana: 1.2

22 Hours in Jo'burg

Today was my first day of work, and it was awesome. I think the obsessively detailed jetlag prevention strategy I was given worked, even if I didn't quite do it right--I was amazingly wide awake today.

I'll start from the beginning, though. I boarded my flight to Jo'burg Saturday afternoon. Aside from the general unpleasantness of any 17 hour flight, and the group of large game hunters surrounding me who spoke loudly about their guns and things they had shot and things they wanted to shoot, the flight was minimally painful.

I arrived in Jo'burg around 5pm Sunday evening. The flight was early, so I had plenty of time to hang out at the airport, pick up a SIM card and stamps, check my large suitcase, etc. Annelene, the friends she was staying with, Ben and Mo, and Ben's little sister Robbynne picked me up at the airport and we went out for a traditional Easter dinner of lo mein and sushi. We then headed to Ben and Mo's apartment in downtown Jo'burg. 

I was amazed at how much Jo'burg changed since my visit in 2009. The neighborhood surrounding the apartment was one in which I got lost and pulled into a garage to ask for directions (/cry/convince myself I would be mugged and carjacked) the last time I was in the city. I was slightly nervous about being there after what I had heard when I was in the city before, but Ben actually stopped at red lights and seemed comfortable being there after dark.

Their apartment was on the 16th--and top--floor of a building undergoing renovations. It was clearly a very nice building at one time, but was outdated and somewhat run-down. I expect that, in a pattern similar to many cities, the building was originally occupied by wealthy whites while blacks and other minorities were confined to townships outside the city. Post-Apartheid, the inner city became almost exclusively black and low-income, and once-luxurious buildings grew progressively more run down. Annelene explained that some areas of downtown were in early stages of gentrification as artsy yuppies, like Ben and Mo--a young, black/coloured, artsy, intellectual married couple--moved in. Renovations are occurring in many of the buildings. Furthermore, the neighborhood seemed safer and more accessible since the Gautrain opened in preparation for the World Cup shortly after I was last there.
 
Luckily, the elevators were working when we got there so we didn't have to climb 16 flights of stairs. The view from the apartment was spectacular. It was a gorgeous apartment with high ceilings and 3 walls of windows. However, it was also the first time I have been in an apartment without a shower. The only way to bathe was actually to take a bath, and you actually had to fill the tub since the hot and cold taps were separate and the temperatures were virtually unbearable on their own. Still after the long flight and sleeping in my clothes, a bath was perfect. We all went to sleep early.

View from 16th floor at night

Sitting room, with view

View in daylight

Balcony with kitchen windows and garden

The next morning, Annelene and I took the train to Rosebank for a lovely brunch outside in the beautiful fall weather. The food was incredible, and the company was better. It was surprising both how many aspects of each others' lives we didn't know about, as well as how comfortable we felt after 4 years of infrequent Skype or Gchat talks. We did not have nearly enough time together, but it was wonderful to see her. I hope to get to see her again while I am in southern Africa.

She accompanied me on the train toward the airport and got off to meet former coworkers for lunch. I continued to the airport for my flight to Gaborone.

With Annelene at Tashas in Rosebank. Note the hanging books as decoration inside. Note also our matching piña coladas (of course!)